Improving Preventive Care in Your Practice Without Burden Edward Curry, MD, FAAP Judith Shaw, EdD, MPH, RN, FAAP Session I2051 : 2016 NCE 10/23/2016

Agenda Introduction & Background Big Winners for Implementation Cases 1 & 2 Maternal Depression Autism Screening Cases 3 & 4 Oral Health Parental Strengths Resources

Faculty Disclosure: Judith Shaw In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. I am one of the editors of the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescent, 3rd Edition. I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation about well child care using the best available evidence to support my conclusions and recommendations.

Faculty Disclosure: Edward Curry In the past 12 months, I do not have any Financial Disclosures I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Changes in Practice Participants will be able to: Plan to implement the Bright Futures/AAP Guidelines for children and adolescents Use pediatrician-tested strategies and Bright Futures tools to improve the quality of preventive services delivered in their clinical setting 5

Bright Futures …is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels. 6

Affordable Care Act: Section 2713 …requires all health plans to cover, with no cost-sharing the services are outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition (Hagan J, Shaw JS, Duncan PM eds.) “with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration,”

Periodicity Schedule Available at: https://www.aap.org/periodicityschedule

Bright Futures Bright Futures is the health promotion/disease prevention part of the medical home At the heart of the medical home is the relationship between the clinician and the family or youth

Making the Most of the Guidelines The Bright Futures Guidelines provide the background and all the details. The question is: How can you incorporate all that into a typical office visit? Use the Guidelines along with other Bright Futures materials Therapeutic relationship is still the key

Overview of Changes & Important Topics Bright Futures Guidelines, 4th Edition (pending) Part 1: Health Promotion Themes 12 chapters highlighting key health promotion themes New themes in development: Social determinants of health; Media use, Children with Special Health Care Needs Part 2: Health Supervision Visits Rationale and evidence for screening recommendations 32 age-specific visits (including prenatal visit) 5 health supervision priorities for each visit Designed to focus visit on most important issues for child that age Includes: social determinants of health, health risks, developmental issues, positive reinforcement

Bright Futures Guidelines, 4th Edition Child Healthy Development Family Support Mental Health and Emotional Well-Being Nutritional Health Physical Activity Healthy Weight Promoting Lifelong Health for Families and Communities Oral Health Healthy Sexuality Safety and Injury Prevention Community Relationships and Resources Promoting the Healthy and Safe Use of Social Media Children and Youth with Special Health Care Needs

Components of a Bright Futures Visit History Surveillance Physical examination Screening Immunizations Anticipatory guidance

Proposed Priorities in the 4th Edition 12 Month Visit Example Social determinants of health (the economic and social conditions that shape the health of individuals and communities) Establishing routines Feeding and appetite changes Establishing a dental home Safety Source: Healthy People 2020

Core Tools: Integrated Format Previsit Questionnaires Allows healthcare provider to gather pertinent information without using valuable time asking questions Documentation Forms Enables Provider to document all pertinent information and fulfill quality measures Parent/Patient Handouts Provides Parental Education all the Bright Future Priorities for the visit

Tool & Resource Kit The Bright Futures Tool and Resource Kit also contains supplementary materials: Additional Parent/Patient Handouts Developmental, behavioral, and psychosocial screening and assessment tools Practice management tools for preventive care Information on community resources All of Bright Futures developed materials are in the public domain brightfutures.aap.org/materials-and-tools/tool-and-resource-kit/Pages/default.aspx

You and your team are the experts Implementing Bright Futures into Daily Practice How it gets done in your practice setting in partnership with your patients and parents You and your team are the experts

Implementing Bright Futures into Daily Practice Can it be done? YES

Implementing Bright Futures New Approaches National AAP Preventive Services Implementation Project (Jan–Oct 2011) Pediatricians, family physicians, nurse practitioners, physician assistants, nurses and office staff Rural, urban and suburban practices and clinics, as well as community health centers and the Indian Health Service Partner with Health Plan and Medicaid QI activities For example: CHIPRA Demo Projects

National AAP Preventive Services Implementation Project (PreSIP) (Jan – Oct 2011) 20

Chart Audit Measurement 9 and 24 Month Visits Eliciting & addressing parental concerns Age appropriate risk assessments Oral health risk assessment Developmental screening/follow-up (9 & 24 m) Autism specific screening/follow-up (24 m) Maternal depression screening (2 m) Evaluation of parental strengths Weight for length or BMI Addressing 3 Bright Futures priorities in AG

PreSIP Data

Office-Based Systems Components Utilize a preventive services prompting system Utilize a recall/reminder system (to address immunizations and well child visits) Utilize a system to track referrals (paper-based or electronic) Utilize a system to identify children with special health care needs Link families to appropriate community resources Utilize a strength-based approach and shared decision-making strategy

Practice-Level System Changes

Bright Futures Preventive Services PreSIP Data Bright Futures Preventive Services

What were the Big Winners? Previsit Questionnaires Which involved follow-up Which involved links to community or in-office systems Documentation forms/Prompting systems Handouts Partnership with Parents Recall and Reminder System

Preventive Services Implementation State Spread Project (PreSIPS2) Pediatric Practices Approx. 10 per Chapter + residency program Chapter Leadership Teams Lead Physician, Project Mgr./QI Coach, State MCH rep, Family rep AAP National Leadership Team & Staff AAP Chapter Participants: Georgia, New Jersey, South Carolina and Virginia 27

Questionnaires Paper Electronic At the visit in the waiting or exam room At home (via email) Make appointment time 15 minutes earlier Practice support and nursing staff in charge of how this happens: Have a staff session to reinforce importance and contribution Train how to distribute Develop a scoring system Develop a system to alert practitioner to know “when ready to proceed” Help parents/youth with literacy or language differences Have all tools and supplies ready Shift some responsibilities from the clinician to non-clinician staff where appropriate

What can you get from a Bright Futures Previsit Questionnaire? Questionnaires cont. What can you get from a Bright Futures Previsit Questionnaire? Maternal depression screening Medical risk screening TB, Lead, Anemia, STIs, Cholesterol Vision and Hearing If possible, practice staff can perform or set up “Parental/youth concerns and questions” for this visit Oral health risk assessment Dental home/fluoride H2O Developmental surveillance for young children Strength/developmental surveillance for school aged children & adolescents

Setting the agenda PRIORITIES Family support Child development and behavior Language promotion/hearing Toilet training readiness Safety

Medical Screening

Developmental Surveillance

Questionnaires cont. Which Bright Futures standardized screenings could be done with additional questionnaires? Developmental screening Autism specific screening Maternal depression screening Excerpt from 2 month previsit questionnaire

What’s Left? Further history including identification of parental strengths Additional visit questionnaire with questions in each of the five visit priority areas BMI Physical exam Answering questions, addressing concerns and anticipatory guidance about five priority topics If a change needs to be considered, use a shared decision-making approach Immunizations

Final Questionnaire Tips from Practices Include tools in the EHR Include pass/fail categories for MCHAT in EHR Include secondary screens for use if screen is positive Staple screening tools to Previsit Questionnaires so the entire previsit packet is provided to parents

Case Studies 1 & 2

Mia Case Study 1: Maternal Depression : 28-year-old married mother of two College educated Currently a high school math teacher, but considering staying at home On 3 month parental leave Husband is computer consultant and travels once a week for job She is well-liked at school and has friends from school and book club With her first child she had a relatively easy adjustment and has a good child care situation

Case Study 1: Maternal Depression cont. Embarrassed that she is having so much trouble Mia is at home and feels like she should be able to do this IF WE DO SCREENING WHAT SCREENING TOOL

Maternal Depression: PHQ-2 Maternal Depression Questionnaire Maternal Depression: PHQ-2 Information from: Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2:validity of a two-item depression screener. Med Care. 2003;41:1284-92. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2280

Maternal Depression Questionnaire Maternal Depression: PHQ-9 Available at: http://www.phqscreeners.com/

Jason Case Study 2: Autism 24-month-old who is only speaking 2 to 3 words. Most of his speech is jibberish. He also has prolonged temper tantrums lasting 15 to 20 minutes Mother brought her concerns to her previous pediatrician at 18 months. She was told boy’s usually talk later and temper tantrums are normal

Jason Case Study 2: Autism cont. M-CHAT-R Screening Bright Future Guidelines Autism screening at 18 and 24 months

M-CHAT-R Screening (excerpt) Case Study 2: Autism cont. M-CHAT-R Screening (excerpt) For more information on autism screening tools, go to: mchatscreen.com/

Establishing a Workflow!!!

Workflow Needs to be Job Specific, not Person Specific Workflow Previsit Questionnaire Workflow Needs to be Job Specific, not Person Specific Starts with Initial Entry Point to Medical Office Receptionist Provides Age Appropriate Previsit Questionnaire Pre-formatted Age Specific Packet (18 Month Packet) 18 Month Previsit Questionnaire CHAT or MCHAT Questionnaire Parent would Complete Questionnaire in Waiting Area Medical Assistant on Rooming Child would Make Sure Questionnaire is Completed MA attaches Questionnaire to Chart or Enter the Results into the EHR Physician Would Review either Paper Copy or EHR Would Document Intervention in Chart Completion of Visit Medical Assistant would Provide Appropriate Parent Handout

Workflow: Autism Screening Physician reviews both Questionnaire and confirms red flag results If child fails two items, physician initiates referral Referral tracking is referred to staff member to follow-up Regional Center Referral Referral to Developmental Pediatrician

Follow-up of Red Flag Results Workflow Screening Questionnaire Follow-up of Red Flag Results Maternal Depression Screening If PHQ-2 Done, then Need to Do PHQ-9 If Positive, then: Low Risk Referral to Community Resources Moderate Risk Social Worker or MFT Emergency Mental Health Evaluation Autism Screening Administer M-CHAT-R If Positive, Set Follow-up Process

Questionnaires How do I address a positive screening response? Maternal depression Referral to OB/nurse midwife, primary care or mental health professional (set up ahead of time) Co-located/employed mental health practitioner in the practice Referral to a mental health professional Adolescent mental health issues More practitioner education and experience Telephone, telemedicine and email support systems Developmental screening Have a developmental behavioral specialist come to practice once a month to see kids with positive screens

Community Linkage Tips from the Practices Systems measure Do you have someone in your office or clinic who is in charge of liaisons with community organizations and updates to accessible list of community resources for parents? Hire a care coordinator, or use current staff with skills in this area Use community liaisons in the practice to handle referrals, communicate with specialists, and coordinate services/resources for families Consider hosting “mixers” with potential referral sources in the community to establish relationships If you have set it up, everything related to a difficult situation goes better

Billing and Coding for Questionnaires Billing & Coding Billing and Coding for Questionnaires When standardized developmental screening tools are administer, scored, and interpreted as part of preventive service visit each screening can be individually coded Appropriate CPT code: 96110

Case Studies 3 & 4

Case Study 3: Oral Health Fernando Fernando is a 9-month-old baby who comes in with Maria, his mother, and grandmother for his checkup Maria has no concerns, but does wonder if he should be feeding himself His parents both work They work opposite shifts so that one often can be there with the baby They have arranged to always have all day Sunday together as a family His grandmother often has him for dinner and breakfast to cover the overlap times and takes special care to prepare his food and feed him He eats table food, some baby food at mealtime and breast milk 4x a day She has utilized the WIC supplements for breast feeding moms

Case Study 3: Oral Health cont. Maria enjoys his happy disposition and his calling out when she comes home from work She is also pleased that he is growing so well on her breast milk and can feed himself the bottle. On his oral health risk assessment… Maria and her mother have many dental caries and have been unable to access dental care Fernando takes bottles in his crib at least twice a day

Strengths Strengthening Families Framework Social Connections/Source of Support Ability to Access Services in Times of Need Knowledge of Child Development Resiliency – Enjoys about Her Baby Child’s Social & Emotional Competence www.cssp.org/reform/strengthening-families

Anticipatory Guidance Priorities 9 Month Visit Family adaptations Infant independence Feeding routine Safety

Case Study 4: Patient/Parental Strengths Samantha 21-year-old mother with an 18-month-old daughter They have just begun living in a homeless shelter Refusing to put her daughter in child care so she can’t get a job Doesn’t have a place to live and doesn’t want to live with her mom anymore no matter what 56

Case Study 4: Strengths cont. Samantha Filled out all the forms Found out that her concerns were Boyfriend's mother had a child with autism Risk factors identified: Grandmother smokes in the house

Doesn’t want to live with grandmother who smokes Case Study 4: Strengths cont. Worried about additional shots because boyfriend’s mother had a child with autism Doesn’t want to live with grandmother who smokes

Search for Strengths Risks need to be identified BUT: Strengths are an essential part of health Look for Resiliency and Strengths: ask about strengths at every encounter! Promoting strengths will enhance interactions with parents Search for strengths Connection Competence/ Mastery Independent decision-making Generosity https://www.reclaiming.com/content/aboutcircleofcourage Copyright University of Vermont

Identified Parental Strengths Case Study 4: Strengths cont. Identified Parental Strengths Has a partner who has been with her and Samantha for 6 months – lives with his parents Wants to have her daughter grow up always feeling safe and smoke-free Helps out at the shelter with reading – went to the library to get the books Finished her GED, works as a waitress, never interacted with an agency before

Anticipatory Guidance Priorities 18 Month Visit Family support Child development & behavior Language promotion/hearing Toilet training readiness Safety

Tips on Strengths from the Practices If you see a parent doing something great, point it out Provide positive feedback during the visit Instead of telling the parent they “should” do something, offer that they “could” do something Share your own experiences as a parent (if applicable) Ask the parents about their role as a parent, how they differ from their own parents, what they like to do with their child Take an interest in the parents Recognize the strength of extended family and offer strategies to assist

Pediatric Preventive Coding Resource Bright Futures and Preventive Medicine Coding Fact Sheet This resource contains comprehensive listings of codes that may not be used by your practice on a regular basis. We recommend that you identify the codes most relevant to your practice and include those on your encounter form/billing sheet.

Education in Quality Improvement for Pediatric Practice (EQIPP) EQIPP Bright Futures, an online learning program, weaves improvement principles and concepts with pediatric-specific clinical content to improve health outcomes. It is designed to identify and continuously close gaps in practice using practical tools. EQIPP Bright Futures courses are currently undergoing revision. It is expected to re-launch within 6 – 12 months. EQIPP participants simultaneously earn CME credit and meet MOC Program Part 4: Performance in Practice requirements. EQIPP is now a member benefit.

brightfutures.aap.org/ Web Site Resources brightfutures.aap.org/

Resources: Parent/Family healthychildren.org General information related to child health and/or more specific guidance on parenting issues Information on AAP policies, guidelines, publications, and other child health resources Tips & tools www.healthychildren.org Brightfutures.aap.org Patient/Parent handouts in the Bright Futures Tool & Resource kit Family Resources Web page Virginia Department of Health educational videos brightfutures.aap.org/ Healthy Child Care America Promotes cognitive, social and physical development of children in early education and child care Supports the needs of health professionals interested in promoting healthy and safe early education and child care programs Resource library (for health care and early education & child care professionals) www.healthychildcare.org/bfutures.html Bright Futures Family Pocket Guide Developed by the National Family Voices Project IMPACT with input from the Bright Futures National Center Easy-to-use book designed to help families support health and wellness for their children at every age (in English and Spanish) www.fv-impact.org/

Changes in Practice: Recap Participants will be able to: Plan to implement the Bright Futures/AAP Guidelines for children and adolescents Use pediatrician-tested strategies and Bright Futures tools to improve the quality of preventive services delivered in their clinical setting Previsit questionnaires Documentation forms Handouts Office systems changes Strength-based approach 67

Questions & Answers

References American Academy of Pediatrics. Bright Futures Tool and Resource Kit [CD-ROM]. Duncan PM, Shaw JS, Gottesman MM, Swanson J, Hagan JF, Pirretti AE, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2010. Duncan P, Pirretti A, Earls MF, Stratbucker W, Healy JA, Shaw JS, Kairys S. Improving delivery of Bright Futures preventive services at the 9- and 24-month well child visit. Pediatrics. 2015. Hagan JF, Shaw JS, Duncan PM, eds: 2008, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.

Contact Information American Academy of Pediatrics Bright Futures National Center Jane Bassewitz, MA Manager, Bright Futures National Center 847-434-7781 Kathy Janies Manager, Bright Futures Implementation 847-434-7785 E-mail brightfutures@aap.org Web site brightfutures.aap.org